ERA21LA238

NTSB accident investigation · Piper PA46R-350T · York, PA · December 30, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 30, 2020, 16:00 local (21:00 UTC)
Place
York, PA · On airport
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N463STPiper PA46R-350T
Defining event
Landing-landing roll: Landing gear collapse
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20201230021989A
Case key
103192

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

An improper weld repair of the engine mount, which resulted in a fatigue failure of the mount and subsequent nose landing gear collapse. Contributing to the accident was maintenance personnel’s failure to accomplish the manufacturer’s service bulletin pertaining to engine mount inspections.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance: repairPersonnel issues › Task performance · Maintenance personnelAll aircraft: 99 cases
Fuselage: engine attach fitting (on fus)Aircraft › Aircraft structures · Fatigue/wear/corrosionAll aircraft: 2 cases
Fuselage: engine attach fitting (on fus)Aircraft › Aircraft structures · Incorrect service/maintenanceAll aircraft: 2 cases
Fuselage: engine attach fitting (on fus)Aircraft › Aircraft structures · Inadequate inspectionAll aircraft: 2 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Landing gear collapseLanding-landing rollAll aircraft: 1,787 casesDefining event

Analysis

During the landing rollout at the conclusion of a cross-country flight, the nose landing gear collapsed. A postaccident examination revealed the engine mount had failed, allowing the nose landing gear (NLG) actuator to impinge the firewall resulting in substantial damage. Further examination of the engine mount revealed that the right-side NLG actuator attachment foot failed from fatigue. The area had been previously repaired by welding, and old resolidified metal was found inside the crack surfaces. The previous weld repair was of poor quality and occurred prior to the owner/pilot purchasing the airplane. There was no documentation of the repair in the maintenance records. Inspection of the engine mount was addressed by a service bulletin (SB) issued by the airframe manufacturer, and there was no record of its compliance during the latest annual inspection of the airplane. The SB also called for the replacement of cracked engine mounts as repairs were not permitted.

Factual narrative

On December 30, 2020, about 1600 eastern standard time, a Piper PA-46R-350T, N463ST, was substantially damaged when it was involved in an accident at York Airport (THV), York, Pennsylvania. The private pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a Federal Aviation Administration (FAA) inspector, the airplane’s nose landing gear collapsed during landing at THV resulting in substantial damage to the airframe. During the subsequent repair of the airplane, mechanics noted that the engine mount failed, resulting in the nose gear actuator impinging the engine firewall and collapsing the nose gear. The failed engine mount was sent to the National Transportation Safety Board Materials Laboratory for examination and analysis. The failed mount was Piper part number (P/N) 89137-041. On the left-side of the mount, several tubes near the nose landing gear (NLG) actuator attachment foot were bent and had been cut, and one tube was fractured near its weld to the attachment foot. Further examination revealed that the fracture surface appeared light gray and was on slant angles; features consistent with a ductile overstress fracture. The right-side NLG actuator attachment foot was also fractured. A closer examination of the attachment foot fracture areas showed deposits of resolidified pools of molten metal. The areas around the deposits were tinted brown and black, consistent with local heating produced by a welding process. The crack in the foot was gaped open, and weld metal deposits spanned and filled the space between the crack faces. Smaller beads of resolidified metal, consistent with weld spatter, were observed fused to adjacent surfaces, including exposed crack faces. Most of the fracture surfaces on the right NLG actuator attachment foot were obscured or obliterated by the postfracture weld process or heavy recontact damage. An area of relatively flat fracture features in planes perpendicular to the forward surface and separated by ratchet marks was observed on the forward side of the right NLG actuator attachment foot; these were features consistent with fatigue fracture. After additional nondestructive cleaning, curving crack arrest lines consistent with fatigue fracture were observed. Piper Service Bulletin (SB) No. 1103F (Engine Mount Inspection), dated September 1, 2015, called for the inspection of PA-46R-350T engine mounts on a recurring basis if the mount had not been replaced by Piper P/N 89137-043. Also, per the SB, if cracks were found during the inspection, the mount was to be replaced; no repairs were permitted. There was no reference in the latest annual inspection, dated July 1, 2020, indicating compliance with the SB. The pilot/owner of the airplane, who purchased it on January 25, 2019, reviewed the maintenance logbooks and reported that there was no documentation of an engine mount weld repair in the records. The date of the weldrepair on the engine mount, therefore, could not be determined.

Aircraft

Registration
N463ST
Reported as
Piper PA46R-350T
Category
Airplane
Serial number
4692073
Built
2008
Airframe hours
1,631
Engine
Lycoming TIO-540-AE2A, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2020
Departed
XSA · Tappahannock, VA
Destination
Same as departure
Flight plan
IFR
Airport
THV · York, runway 17/35, 5,188 × 100 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Onboard weather, Handheld GPS

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
1,598 total · 188 in this make and model · 1,598 as pilot in command · 32 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 19 °F
Altimeter
30.20 inHg
Icing
Clear
Observed at
KTHV
METAR
METAR KTHV 302053Z AUTO 17005KT 10SM CLR 06/M07 A3020 RMK AO2 SLP232 T00561067 56034

Docket · 9

The files NTSB released with the investigation on October 21, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.